Inspection on 08/09/06 for Tanfield House

This inspection was carried out on 8th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tanfield House 15/08/07

Tanfield House 27/10/05

Tanfield House 24/05/05

Tanfield House 02/12/04

Tanfield House 28/06/04

Tanfield House 11/02/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Tanfield House 80 Randall Avenue Neasden London NW2 7SS Lead Inspector Julie Schofield Key Unannounced Inspection 8th September 2006 09:20 Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tanfield House Address 80 Randall Avenue Neasden London NW2 7SS 020 8452 6616 020 8830 5826 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Lucille Rabor Amanda Rabor Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: Tanfield House (80 Randall Ave) is situated on the corner of Randall Avenue and Tanfield Avenue and is close to the shops in Neasden. Tanfield Avenue is on a bus route and it is relatively close to the North Circular Road. The nearest underground station is Neasden. It is a large detached house with a small garden at the front of the house and a garden at the rear of the property. The garage at the side of the house has been converted into an office for the nursing agency that is also operated by the company. There is parking space available on the street outside the house. The home is registered for 5 adults with mental health problems and there are bedrooms on both the ground and first floor with bathing and toilet facilities on both floors. Communal space is situated on the ground floor and consists of a lounge and a separate open plan kitchen /dining area. There is a small office/sleeping in facility on the first floor and an office on the ground floor. At the time of the inspection there were no vacancies. Details of the fees charged may be obtained from the home, on request. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Friday in September and started at 9.20 am and finished at 4.05 pm. The Inspector would like to thank the manager Ms Amanda Rabor, the proprietor Ms Lucille Rabor, the staff on duty and the resident for his comments during the inspection. The inspection consisted of discussions with the manager, members of staff and 1 resident, a tour of the building but not all residents’ bedrooms, examining records and observing care practices. The wishes of other residents who did not want to give their comments during the inspection were respected. What the service does well: What has improved since the last inspection? What they could do better: Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comprehensive assessment of the needs of the resident, prior to admission to the home, enables the home to determine whether a service tailored to the individual needs of the resident can be provided. A programme of preadmission visits to the home enables the prospective resident to sample life in the home and to decide whether the service provided is acceptable. A record of the content of these visits must be kept so that the home can demonstrate that the needs of the prospective resident are compatible with those of existing residents. EVIDENCE: The manager said that 1 resident had been admitted to the home since the last inspection and their case file was examined. There was evidence of a comprehensive assessment of need prior to the admission of the resident and this included reports by the OT, the social worker, the psychiatrist, the nursing report and risk summaries etc. There was a copy of the minutes of the last CPA review meeting and minutes of the meeting held prior to the resident’s discharge from hospital. There was also a record of the visits made by the manager to meet the resident prior to their admission and of an admission form being completed by the placing authority. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 9 A member of staff discussed the period prior to a resident’s admission to the home and said that by having a programme of trial visits (2 or 3 visits including an overnight stay) the prospective resident is helped to get to know the staff team and other residents, to get used to a new environment and to feel comfortable with being in the home. There was a record on the case file of the resident’s visits to the home. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans have been drawn up for each resident so that the service provided can meet the individual needs of the resident. The home is able to demonstrate that changes in the needs of residents are identified and addressed through a system of regular review meetings. The resident’s right to make decisions about their life in the home is respected. Responsible risk taking contributes towards the resident leading an independent lifestyle and reviewing these ensures that the changing needs of residents are identified and addressed. EVIDENCE: Three case files were examined. Files contained a care plan and evidence of placement review meetings, internal review meetings and CPA meetings being held. The residents sign the care plan. The format of the care plan, which had changed at the beginning of the year, now consisted of the areas of building a trust relationship, schizophrenia, social isolation, non-compliance and risk for Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 11 others. Each aspect of the plan identified the problems, listed the expected outcomes and set out the interventions necessary and the rationale behind these. Aspects of the care plans were reviewed on a monthly basis. Files also contained daily plans advising staff on how to support the resident. None of the residents receive support from advocacy services. Residents manage their own finances and no one from the company is an appointee for any resident the home. Staff will help residents with any benefit problems or enquiries if these arise. Staff respect the residents’ right to make decisions and choices within their day to day to living. Residents decide when they go to bed at night and when they get up in the morning. Residents choose how they wish to spend their day although they are encouraged to socialise and to use their time in a purposeful manner. They choose what to wear, when to go out of the home and when to return, what to spend their money on, how to use their leisure time etc. Each case file contained risk assessments, tailored to the individual needs of the residents. The risk assessment identified a particular task or activity, detailed the potential hazards involved and set out the support needed. There were risk assessments in respect of falling, riding a bike, staying out late, provision or non-provision of keys to bedroom doors or to the front door etc. There was evidence that these were reviewed and changes made if necessary or assessments removed when no longer relevant. It is recommended that a system be introduced to review all risk assessments when the care plan is reviewed. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Taking part in activities and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. The home is to be commended for its introduction of sessions in the home arranged by an OT, which have provided residents with new interests, which could help with future employment opportunities. Residents are encouraged to maintain contact with their families and friends so that their need for fulfilling relationships are met. Residents are encouraged to become more independent by making decisions and by having their wishes respected. Residents are offered a balanced diet to promote their well being and the diet respects their cultural needs. Some minor repairs in the kitchen are required. EVIDENCE: The manager said that unfortunately the resident who had been attending college had stopped although it is hoped that he will be accepted for a short course early in 2007. One of the other residents is starting a college course in September (3 days a week for a construction course and 1 evening a week for Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 13 a computer course). One resident is looking for part time voluntary work, with the assistance of Qest. A resident who has problem with his sight is awaiting delivery of a specialised computer system, which will assist his reading. The manager said that residents are encouraged to use community resources and facilities and these have included leisure centres, cinemas, libraries and shops. A resident confirmed that he used libraries, shops, banks and hospitals. Staff are available to assist residents in the community, when required. They have escorted them to out patient appointments at the hospital or when then the resident is buying new clothes. The names of residents are entered on the electoral roll although it is the resident’s choice whether they wish to vote at the elections. The company employs an occupational therapist that spends part of their time working in Tanfield House with the residents. The OT visits the home twice a week and works with residents on a group and on an individual basis. The OT does computer training, cookery, shopping and art and pottery sessions. A resident confirmed these visits and said how much he enjoyed the cooking and painting. The manager previously said that the computer sessions were something which residents may find useful in the future in terms of employment. The manager said that the company had not tried to arrange an annual holiday for residents after the residents refused to go on holiday last year. She had tried to arrange a day trip to Brighton and all but one resident changed their mind at the last moment. The resident said that they would like to go to a rap event and this was arranged. Two of the residents have been to music festivals together during the summer. Residents enjoy both personal and telephone contact with their families. Residents’ families are welcome to visit the resident in the home and visits can take place in the privacy of the resident’s room. Some residents choose to make visits to their family. Residents can and do decide not to receive visitors e.g. when they think that the visit is too late in the evening. Some residents have friends that visit the home. A member of staff talked about supporting residents and said that it was important to show residents respect and to remember that it is their home. It was observed during the inspection that staff knocked on the bedroom door and waited to be invited into the room before entering. It was also noted that letters were delivered to residents, unopened. The manager said that at the moment all of the residents have a key to their bedroom and to the front door. A resident confirmed that they helped to keep their room tidy and to do their laundry. A member of staff said that some residents help with the preparation of the meal, under supervision from staff on duty. Although the dining area is small and could not accommodate all residents seated together staff said that Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 14 residents prefer to eat at different times, depending on their habits or preferences. Meals are included on the menu to meet the cultural needs of residents e.g. West Indian food and staff said that a Somali outreach worker had taught them how to cook meals for a Somali resident. The content of the lunchtime menu has been reviewed and amended many times to meet the preferences of residents. A recent comment, at a meeting with residents to discuss the menus, about too many chips in lunchtime meals has resulted in more pasta and jacket potato dishes being included. Menus and individual food records were inspected. The menu was varied and records were up to date. The member of staff on duty was cooking a meal for residents in Tanfield House and for residents in Jerome House. A statutory requirement was identified during the previous inspection that the home was to forward written confirmation from the Environmental Health Officer that the practice of cooking meals in one of the company’s care homes and then carrying them to another care home is acceptable. This remains outstanding. It was noted that the work surface in the kitchen area had been patched up with fablon and that the wash hand basin for the use of persons preparing food was cracked. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive prompting with personal care in a manner, which respects their privacy and dignity. Residents’ health care needs are met through access to health care services in the community. Residents’ general health and well-being is promoted by staff that assist the resident to take prescribed medication in accordance with the instructions of the resident’s GP and psychiatrist. However records of the administration of medication need to be up to date. EVIDENCE: A member of staff said that confidentiality was the key to a good working relationship with the residents and that it encouraged residents to learn to trust members of staff and to feel safe. In respect of personal care she said that the current residents needed prompting or reminding rather than direct assistance and thought that personal hygiene and a smart appearance was important when residents were using community resources. Routines within the home were flexible and residents chose their own clothing and hairstyles. Files contained daily plans for how staff are to provide support to residents. Residents are able to choose when to get up in the morning and when to go to Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 16 bed. The residents are African Caribbean and African and there are African Caribbean and African members of staff. When examining case files it was noted that there was evidence of access to health care services within the community e.g. the optician, the dentist, chiropodist and the GP. Annual medical checks were arranged for residents with the GP. There was a record of appointments with the psychiatrist and of CPA meetings. Out patient appointments had been arranged when necessary. There was evidence of routine screening e.g. blood tests to monitor sugar and cholesterol levels. A member of staff on duty confirmed that they had received medication training. The storage of medication was inspected and was satisfactory and secure. The administration of medication was inspected. The home uses the nomad cassette medication card, supplied by the pharmacist. The system has been introduced since the last inspection. The empty blisters were appropriate for the time of day and for the day of the week on which the inspection visit took place. Records were inspected. Records were up to date and complete for 4 of the 5 residents. It was noted that for 1 resident there were no records of the administration of zoplicone, to be given at night, for the 7 nights prior to the inspection although the blisters were empty. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are aware of their right to complain if the care that they receive is not satisfactory. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. EVIDENCE: A complaints procedure is in place in the home. A copy is placed in the service user guide and this document is given to each resident, as part of the admission procedure. The manager said that no complaints from residents have been recorded since the last inspection although the next door neighbour has raised concerns about noise levels, particularly late at night and in the early hours of the morning. A resident said that they were satisfied with the service provided but if there was anything that they were not satisfied with they felt able to speak to someone in the home and mentioned the name of the registered manager. The manager said that residents give feedback at any time and it was noted that when she was in the home residents stopped to speak with her. The home prefers to deal with matters before complaints develop and has a system of meetings, which are recorded, taking place between the resident and manager and/or key worker. A protection of vulnerable adults procedure is in place. The manager said that no allegations or incidents have been recorded since the last inspection. There was evidence on the staff files that protection of vulnerable adults training had taken place. A member of staff confirmed that she had undertaken training in Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 18 adult protection procedures and was aware of her duty to report any disclosures of abuse to the manager. She discussed the implications of the whistle blowing procedure for members of staff. The manager said that the home does not practice restraint. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 30 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a home, which is comfortably furnished and provides a pleasing environment for residents to relax and enjoy. The privacy of residents is respected by the provision of single bedrooms although a damaged windowpane needs to be replaced. Bathing and toilet facilities in the home are sufficient in number and are conveniently located within the home to protect the dignity of residents. A lock on each door is needed to protect the residents’ privacy. Residents have sufficient communal space in which to dine and to socialise. Residents live in a home where overall standards of cleanliness are good. However staff lack training in infection control procedures. EVIDENCE: During the inspection a partial tour of the building took place. Four of the residents were in their bedrooms and did not wish to be disturbed. It was noted that since the last inspection the outside of the house has been painted and with the neat garden at the front of the house the first impression of the house is one of a well maintained property. Inside the house the furnishings and fittings are of a good quality and a new 3-piece suite has been purchased. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 20 The home is bright and airy and appeared “homely”. A resident said that they were pleased with the upkeep of the home and with its location and one of the reasons why he was satisfied with the choice of home is because it was quiet. Each of the 5 residents has their own single bedroom. Each room contains a wash hand basin and is at least 10 square metres in size. Two of the bedrooms are situated on the first floor and 3 of the bedrooms are situated on the ground floor. One of the panes in the window of a first floor bedroom was boarded up as it was cracked. A resident said that they were satisfied with their room and that he could relax in his room. Bedrooms are situated on the ground and first floors and there are toilet and bathing facilities on each level. It was noted that there was no lock on the toilet door on the first floor. Communal space in the home consists of a lounge at the front of the house and an open plan kitchen and dining area at the back. The lounge is comfortably furnished and decorated. If residents wish to smoke the policy of the home is that residents go outside in the garden at the rear of the house. During the inspection the Inspector spoke to one of the residents who was sitting on the patio area, smoking a cigarette. The garden also has a lawn area and trees and shrubs. Pears from the tree had fallen on the grass beneath. There is an office on the ground floor, which is used by the manager and an office/sleeping in room on the first floor, which is used by the staff on duty. It was noted during the partial tour of the premises that areas inspected were clean and tidy and free from offensive odour. A member of staff on duty said that they had not undertaken training in infection control procedures and the manager said that training in respect of this had not yet been arranged for the staff team. Residents receive support from staff to service their laundry. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from support from staff that have received training in mental health issues. NVQ training enhances the general skills and knowledge of carers and the home has met the target of at least 50 of carers achieving an NVQ level 2 or 3 qualification. The rota failed to demonstrate that there are sufficient staff on duty to support the residents and to meet their needs or that the manager’s hours spent on site are sufficient to supervise staff and to monitor the standard of care. Recruitment practices, which include checks and references, protect the welfare and safety of residents and the home needs to ensure that an enhanced CRB disclosure, naming the company as the employer, is obtained for each member of staff. The home has a training and development plan, which is linked to the aims of the home and it provides new staff with induction training. Individual supervision sessions enhance the overall support available to staff and are an opportunity to discuss working practices and to encourage personal development. They need to be carried out on a regular basis. EVIDENCE: Since the last inspection training in mental health has been arranged for the staff team and a member of staff on duty confirmed that they had attended. She also confirmed that she had completed her NVQ level 2 training and would Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 22 shortly be starting a level 3 training course. A discussion took place with the manager regarding the progress made by the home in meeting the target of 50 of carers achieving an NVQ level 2 or 3 qualification. Of the 10 names on the staff rota, 1 member of staff is an RMN, 3 members of staff are undertaking NVQ level 2 training, 2 members of staff have completed their NVQ level 2 training, 2 members of staff have completed their NVQ level 2 training and are undertaking level 3 training, 1 member of staff is doing a counselling course and 1 member of staff is in the 3rd year of a nursing course. The home has therefore met the target of 50 of staff working in home that have achieved an NVQ level 2 or equivalent qualification. A resident described members of staff as “helpful and compassionate”. At the start of the inspection there were 2 members of staff on duty and the manager and proprietor joined the inspection later. A copy of the rota was available for inspection. It was noted that although there were 2 names on the rota for 6 of the 7 shifts from 8am to 3pm that the second name on 5 of the 6 shifts had “floating support” attached to it. A member of staff confirmed that this meant that they would be based at Tanfield House but could be reallocated to one of the other care homes in the company, if necessary. A statutory requirement was identified during the previous inspection that where members of staff worked in more than 1 of the company’s care homes the total hours worked for the week must be recorded on each of the rotas. This was still outstanding. It was noted that on 3 days there was only 1 member of staff listed for the 3pm to 8pm shift. A statutory requirement was identified during the previous inspection that the hours worked in the home by the registered manager are recorded on the rota. Although the hours were now recorded they only amounted to 23 hours per week. Three staff files were examined. Each file contained an application form, 2 satisfactory references, contract, proof of ID and evidence of right to work. Although each file contained an enhanced CRB disclosure, the CRB on two files had been obtained by a previous employer. There is a training plan and staff receive induction training, have access to NVQ training, receive training to enable them to meet the needs of the residents and receive training in safe working practice topics. Each staff file contains details of the training that the individual member of staff has undertaken. A member of staff confirmed that staff received support in their work through general staff meetings for all staff working for the company, which are held every month, and being sent a company newsletter. She said that she had just taken part in an individual supervision session and that these were held every 3 months. Records confirmed that although staff had received supervision approximately 6 times last year only 2 or 3 sessions had taken place this year. Members of staff had access to the manager and the proprietor if they wished to discuss any concerns and the member of staff said Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 23 that “mini staff meetings” were held in the home if there was a particular matter to discuss. Files contained evidence of annual staff appraisals but these had taken place in July 2005 and this year’s programme had not commenced. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42, Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager continues to develop her knowledge through further training and this contributes towards understanding the needs of residents and staff. Service satisfaction questionnaires help to monitor the quality of the service provided to residents and contribute towards the development of the service and when these are returned the information needs to be incorporated into the development plan. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents. Regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use. EVIDENCE: The registered manager has completed her Registered Manager’s Award and has shown evidence of this on a previous inspection. Since the last inspection Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 25 she has attended “Prevention of Relapse” training. She is currently studying for a degree in psychology and said that she is completed half of the course. There are systems in place for receiving verbal feedback from residents, which include meetings with the key worker (recorded), group meetings with residents (recorded) and 1 to 1 discussions with residents that can take place on a daily basis. The minutes of the last group meeting, which took place on the 4th September, were available. A statutory requirement was identified during previous inspections that information obtained from quality assurance systems is used to draw up a development plan for the home. The manager previously said that satisfaction survey forms have been developed and they were available for inspection. The home has distributed these to family members of the residents, to the CPN’s, to social workers etc. When a significant number have been returned the manager said that the information would be collated and used in the development of the service. At the moment the home has a combined business and development plan. A member of staff confirmed that she had received training in safe working practice procedures i.e. fire safety, first aid, food hygiene and manual handling. There were brief, recorded risk assessments for manual handling, first aid, COSHH products, fire safety and household appliances. There were valid certificates for the testing/servicing of the smoke detectors, extinguishers, portable electrical appliances, and Landlord’s Gas Safety Record. The electrical installation had been checked on the 8/3/02 but the page of the report, which states when the installation next requires checking, was absent. There was evidence that the fire alarms are tested on a weekly basis and that a drill is undertaken at the same time. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 2 26 X 27 2 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 1 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA4 Regulation 12.3 Requirement That the reactions of other residents, views of members of staff on duty and comments made by the prospective resident during the preadmission visits to the home are recorded. That confirmation in writing, from the environmental health officer, that the practice of cooking a meal in one care home and then carrying the cooked food over to another care home is safe, is forwarded to the CSCI. (Previous timescale of the 1st December 2005 not met) That the work surface in the kitchen is repaired or replaced and that the cracked wash hand basin in the kitchen is replaced. That the records of the administration of medication to residents are up to date and complete. That the damaged windowpane in the first floor bedroom at the back of the house is replaced. That the toilet door on the first floor is lockable. That all staff undertake training DS0000036103.V289599.R01.S.doc Timescale for action 01/11/06 2 YA17 16.2 01/12/06 3 YA17 23.2 01/12/06 4 YA20 13.2 01/10/06 5 6 7 YA25 YA27 YA30 23.2 23.2 18.1 01/11/06 01/10/06 01/01/07 Page 28 Tanfield House Version 5.1 in infection control procedures. 8 YA33 18.1 That the rota demonstrates that there are sufficient staff on duty at all times to support residents. (Previous timescale of 01 August 2005 and the 1st December 2005 not met). That the hours worked on site by the manager, and recorded on the rota are a minimum of 35 hours per week. That when a member of staff works in more than 1 Randall care home the total weekly hours worked across the homes are recorded on each home’s rota. (Previous timescale of 1st December 2005 not met) That each member of staff has an enhanced CRB disclosure, naming the company as the employer, prior to commencing work and that applications are made for any that are outstanding. That staff receive individual supervision sessions, which are recorded, a minimum of once every 2 months. That the feedback obtained from quality assurance systems is used to plan and develop services and to formulate an annual development plan, a copy of which is forwarded to the CSCI. (Previous timescale of the 1st January 2006 not met). 01/10/06 9 YA33 17.1S4.7 & 18.2 18.1 01/10/06 10 YA33 01/10/06 11 YA34 19.1 01/12/06 12 YA36 18.2 01/12/06 13 YA39 24.2 01/12/06 Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA9 YA28 YA36 YA42 Good Practice Recommendations That all risk assessments on file are reviewed when the care plan is reviewed. That the fruit is removed from the grass, on which it has fallen. That the programme of annual staff appraisals is completed by the end of November 2006. That the manager contacts the company that checked the electrical installation in the home and establishes when the next inspection of the system is due. Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tanfield House DS0000036103.V289599.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!